Question

The nurse cares for a client following a head injury. Based on the Glasgow Coma Scale, which assessment would place the client in the classification of moderate traumatic brain injury?

1) The client has no eye response to pain, has no verbal response, and extends in response to painful stimuli.
2) The client opens eyes to command, uses inappropriate words, and demonstrates purposeful movement to painful stimuli.
3) The client opens eyes spontaneously, is oriented, and obeys commands for movement.
4) The client opens eyes to pain only, uses incomprehensible speech, and flexes in response to painful stimuli.

Answer 1

Based on the Glasgow Coma Scale, a client with no eye response to pain, no verbal response, and extension in response to painful stimuli would be classified as having a severe traumatic brain injury, not a moderate traumatic brain injury.

Step-by-step explanation:

Based on the Glasgow Coma Scale, a client would be classified as having a moderate traumatic brain injury if they exhibit the following assessment:

1. The client opens eyes to pain only, uses incomprehensible speech, and flexes in response to painful stimuli.

In this case, the client does not have any eye response to pain, has no verbal response, and extends in response to painful stimuli, which falls into the severe traumatic brain injury classification.

The client opening eyes spontaneously, being oriented, and obeying commands for movement would be categorized as minor traumatic brain injury.

The client opening eyes to command, using inappropriate words, and demonstrating purposeful movement to painful stimuli would be considered as having a mild traumatic brain injury.